Menopause

What to Expect, How to Cope

For most women, menopause—the cessation of menstrual periods—is a normal, natural occurrence. The average age at menopause is 51, although any time after 40 is considered normal. The years leading up to the menopausal transition—a time known as the perimenopause—may be characterized by changes in the menstrual period, hot flashes (a sudden feeling of warmth, sometimes accompanied by sweating), emotional ups and downs, sleep disturbances, and vaginal dryness. Some of these symptoms may continue after menopause. The severity of symptoms varies dramatically from person to person, ranging from barely noticeable menstrual changes to an experience described as debilitating. Women who experience menopause abruptly because of the surgical removal of their ovaries (called surgical menopause) typically have much more severe symptoms than women who experience a natural menopause.

Both the perimenopausal and postmenopausal periods may present additional challenges for women who have diabetes. For one thing, the hormonal fluctuations that are common to perimenopause can affect blood glucose levels. For another, some symptoms of menopause are the same as or easily confused with the symptoms of high or low blood glucose levels, so the cause must be determined before corrective action can be taken. In addition, both diabetes and menopause raise a woman’s risk of osteoporosis, so women with diabetes must be proactive about taking steps to keep their bones strong. Lack of sleep, whether related to menopause, stress, or something else, can disrupt diabetes control. And menopause is often associated with weight gain, which can make blood glucose control more difficult.

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The menopausal process

A woman is said to be postmenopausal one year after her final menstrual period. Menstrual periods may be very irregular in the years leading up to the final period, sometimes with only one to three cycles occurring per year in the late perimenopause. A small percentage of women stop having periods abruptly without any cycle fluctuation. Although fertility declines sharply after age 40, perimenopausal women can become pregnant, so contraception is necessary for sexually active women who do not wish to become pregnant until menopause is confirmed. Once a woman has gone a year without a period, she can no longer become pregnant.

As the ovaries age, they become less responsive to the hormonal messengers on which they rely for regular function, and greater amounts of estrogen and progesterone are required for ovulation and menstruation to occur. The perimenopausal years are characterized by fluctuating, although not necessarily low, levels of these hormones. The unstable levels of estrogen and progesterone contribute to menstrual cycle irregularities and perimenopausal symptoms. They can also contribute to unstable blood glucose levels. While the effects of estrogen and progesterone on diabetes control are not entirely understood, in general, it appears that higher levels of estrogen may improve insulin sensitivity, while higher levels of progesterone may decrease insulin sensitivity. When insulin sensitivity decreases, more insulin is needed to get glucose into the cells.

The changes associated with perimenopause commonly begin about three to five years before a woman’s final menstrual period, although some women notice subtle changes as early as their late 30’s. Eventually, the ovaries become unresponsive and unable to ovulate (release eggs). Once the ovaries cease ovulating altogether, estrogen levels decline, and menstrual periods stop. However, hot flashes, night sweats, sleep disturbances, and mood fluctuations may continue for several years. Vaginal dryness due to low estrogen levels may persist if not treated.

Is it menopause or my diabetes?

One of the challenges for menopausal women who have diabetes is distinguishing between the symptoms of the two conditions. It is not uncommon to mistake menopause-related hot flashes or moodiness for symptoms of low blood glucose. Night sweats—hot flashes that occur at night—can interrupt sleep and lead to excessive daytime fatigue, which can also be mistaken for low blood glucose. If this leads to eating extra calories to raise a low blood glucose level, it could lead to high blood glucose and, over time, weight gain, if repeated on a regular basis.

The reduced estrogen levels that occur with menopause can directly cause or can raise a woman’s risk of vaginal dryness, vaginal infections, and urinary tract infections—but so can high blood glucose levels. While all of these conditions are treatable, the cause of the problem must be determined for proper management. Regular blood glucose monitoring can help women figure out whether low or high blood glucose levels may be causing their symptoms. Any woman who is experiencing chronically high blood glucose levels should address that issue first, with the help of her diabetes team, if needed.

Dealing with menopausal symptoms

But what if the symptoms are related to menopause and not high or low blood glucose levels? How does a woman with diabetes successfully treat the most common symptoms of the menopausal phase, including hot flashes, night sweats, moodiness or irritability, weight gain, and vaginal dryness? The answer depends on the severity of symptoms, as well as the degree of control the woman has over her diabetes. Women with poorly controlled diabetes are at increased risk of cardiovascular complications associated with hormone therapy, and are therefore less suitable candidates for this type of treatment.

Lifestyle changes are always the first step to help reduce the discomforts of menopause. The following changes can help make the menopausal transition easier:

Substitute whole grains and fresh fruits and vegetables for processed and refined foods, both to help control blood glucose (and blood pressure) levels and to increase overall energy level.

Use alcohol and caffeine in moderation or not at all, since they can trigger hot flashes and decrease sleep quality. If spicy foods have a similar effect, reduce your intake or avoid them altogether.

Consume more legumes (beans and peas), soy foods, and flaxseed. These foods contain phytoestrogens, or chemicals found in plants that may act like estrogen in the body. Some women report that increasing the amounts of these foods in their diet decreases the frequency and severity of their hot flashes, although scientific studies have not confirmed this. (Phytoestrogen pills and powders are not recommended at this time because of safety concerns).

Get adequate amounts of vitamins and minerals. To keep their bones strong, women going through menopause who are not receiving hormone therapy should be getting 1,200–1,500 milligrams of calcium and 800 international units of vitamin D each day (which can be provided by three to four 8-ounce servings per day of low-fat milk or yogurt). Women receiving hormone therapy should aim for 1,000 milligrams of calcium per day. Vitamin E and the B vitamins have also been suggested as beneficial for reducing menopausal symptoms, but the research does not currently provide strong support.

Use of herbal teas or supplements may be helpful for treating hot flashes and night sweats. Research is limited, but herbal preparations such as black cohosh, garden sage, and motherwort are used in many Asian and European countries. However, you should speak with your doctor before beginning any sort of herbal regimen.

If you are a smoker, stop smoking.

Coping with hot flashes

In addition to the lifestyle changes already described, there are many simple techniques that may help to relieve minor to moderate episodes of hot flashes. These include the following:

Avoid heat around the face area from devices such as hair dryers and curling irons.

Avoid using hot tubs, and keep baths and showers tepid or cool.

Drink cold water or water with ice.

Wear layers of clothing so you can take off some clothing, if needed.

Sleep with a light blanket or other covering and with the windows open or a small fan blowing directly on you.

Use a ceiling fan or air conditioner if you have one.

Place cold compresses on your face when you experience hot flashes or sweating.

Treatment for severe symptoms

Hormone therapy (HT) can be used to alleviate severe menopausal symptoms, especially unrelenting hot flashes, night sweats, and vaginal dryness. Estrogen therapy (ET) is appropriate only for women who have had a hysterectomy (removal of the uterus) because estrogen alone increases the risk of uterine cancer. Women who wish to use hormone therapy who have not had a hysterectomy must use a combination of estrogen and progestin together, called estrogen-progestin therapy (EPT).

Hormone therapy is the only FDA-approved medicine for the treatment of hot flashes and night sweats. Many women report that other menopausal symptoms such as insomnia, mood instability, and lack of concentration are also improved when taking HT, although scientific data has not confirmed these claims.

However, the benefits of HT must be weighed against the risks, such as those recently documented in the Women’s Health Initiative, a large scientific study looking for ways to prevent a variety of conditions in postmenopausal women. According to the results of this study, there is a slightly increased risk of heart attack (7 more cases per 10,000 women per year), stroke (8 more cases per 10,000 women per year), and potentially life-threatening blood clots to the lungs (8 more cases per 10,000 women per year) for women taking EPT. In addition, dementia risk appears to double, increasing from 22 cases to 45 cases per 10,000 women per year.

For women with a hysterectomy taking ET, the risk of heart attack did not increase, but the risk of stroke did increase (13 more cases per 10,000 women per year). In women taking EPT, but not those taking ET, breast cancer increased by 8 cases per 10,000 women per year.

Because women with diabetes already have an increased risk of heart disease, it is especially important for women with diabetes to discuss the benefits and risks of HT with their health-care provider. Heart disease is the leading cause of death of American women.

On the plus side, HT use was associated with 5 fewer hip fractures per 10,000 women per year and with 6 fewer cases of colorectal cancer per 10,000 women per year in the Women’s Health Initiative. HT is approved for the prevention of osteoporosis.

There have been some studies suggesting that taking estrogen promotes insulin sensitivity, which may in turn lead to a lowering of blood glucose levels. (The combination of estrogen and progestin, however, does not seem to have this effect on blood glucose control.) However, this benefit alone is not considered a reason to use estrogen, since there are other, safer options for the prevention and treatment of insulin resistance (namely weight loss and increased physical activity).

Some women should not take HT or should only take it with extreme caution. Hormone therapy is not considered an option for women who have a personal history of breast cancer, although a family history alone does not prevent most women from being candidates for HT. Estrogen therapy is usually not appropriate for women with a history of severe blood clotting disorders or other medical conditions that are exacerbated or complicated by supplemental estrogen, such as liver disease and certain cancers.

Some nonhormonal medicines have been shown to improve hot flashes for some women and are most often used in women with severe symptoms who cannot or choose not to use hormones. These medicines include certain antidepressants, blood pressure medicines, and neurologic medicines.

Vaginal and urinary symptoms

The decrease in estrogen levels that accompanies menopause can make the tissues of the vulva, the lining of the vagina, and the urethra thin, dry, and less elastic and can cause shortening of the urethra. These changes can lead to decreased lubrication, vulvar burning, pain, and sometimes bleeding with sexual activity. They can also increase the likelihood of developing vaginal infections, noninfectious vaginitis (inflammation of the vagina not caused by infection), and urinary tract infections.

Topical, nonprescription lubricants can provide temporary relief from vaginal dryness and assist with sexual activity, although they do not reverse the long-term tissue changes that result from estrogen loss. Over-the-counter vaginal moisturizers can help relieve the symptoms of vaginal dryness such as itching and burning, but such products do not supply estrogen to the tissues and therefore do not treat the underlying cause of the vaginal dryness. A prescription vaginal estrogen product such as a cream, tablet, or ring administered directly to the vagina, on the other hand, can cause genital and urethral tissue to become thicker, more elastic, and moist. Vaginal estrogen is not thought to carry the same risks as systemic hormone therapy (therapy that affects the entire body, such as HT administered in pill or patch form) because vaginal estrogen probably does not get into the bloodstream in any significant amounts.

While replacing vaginal estrogen can decrease the risk of urinary tract infections and also tends to decrease the need to urinate frequently that often accompanies estrogen loss, an existing urinary tract infection should be treated with antibiotics.

Weight gain

For a number of reasons, women are prone to accumulating excess body fat, whether or not they have diabetes. Unlike male hormones, which keep muscle mass high, female hormones promote fat formation. The fat is typically deposited first on the thighs and buttocks, then the stomach, followed by the upper body and arms. Women with Type 2 diabetes or the metabolic syndrome, however, typically accumulate fat in the abdominal region.

In addition to biological factors, certain lifestyle choices can also lead to increased body fat. Skipping meals and following “crash” diets can actually lead to weight gain in the long term by causing the body to slow down its metabolism and use calories more efficiently. The key to weight loss, therefore, is to eat regularly scheduled meals, choose healthful foods containing whole grains, fruits and vegetables, reduce your fat intake, and consume smaller portions.

Losing even 10 to 20 pounds can help you control your blood glucose levels more easily, as well as improve your circulation, blood pressure, and heart health. Increasing your level of physical activity can help with all of these goals, and it’s good for your diabetes control and heart health even if you don’t lose weight. The following are some strategies for putting an exercise plan into action:

Set small goals. If you are currently not physically active, start out by walking for 5 to 10 minutes, three days a week. Increase your time and distance gradually.

Do an activity you enjoy. Try walking, swimming, water exercises, using an exercise bike, or taking yoga or Pilates classes. Doing more than one type of physical activity works different parts of your body and can keep your exercise routine from becoming stale.

Exercise with other people who keep you motivated.

Keep a log of your activities, both for motivation and to see how physical activity affects your blood glucose levels.

Become more active in your daily life. Small steps such as taking a walk during your lunch hour and taking the stairs instead of the elevator can add up.

Exercise one to two hours after eating. This will help control blood glucose levels.

A unique journey

Perhaps the most important thing a perimenopausal woman can do is to listen to and respect her body. Just as each person’s diabetes requires an individualized plan for control, so is each woman’s experience with menopause unique. Because it’s common to experience some changes in blood glucose control as you go through menopause, it helps to maintain a regular schedule of blood glucose monitoring, as well as good exercise and eating habits. Using relaxation techniques to reduce stress and trying to get adequate sleep can help, too. Consult your medical provider if your symptoms are severe and are dramatically affecting your quality of life.

If you are interested in trying hormone therapy or taking other medicines to control your symptoms, talk to your health-care provider about the benefits and risks as they relate to your personal health. This article and “Resources for Readers” can help you to formulate a list of questions or concerns to bring up at your appointment. The goal of balancing diabetes control and menopause symptoms should be to remain strong and vital so you can maximize the quality of your life.

Pat Dougherty is a Certified Nurse Midwife and Nurse Practitioner in the Department of Obstetrics and Gynecology, Division of Midlife Health, in the University of Virginia Health System. She is also certified as a Menopause Practitioner by the North American Menopause Society. Joyce Green Pastors is a Diabetes Nutrition Specialist with the Virginia Center for Diabetes Professional Education and an Assistant Professor of Medical Education in Internal Medicine, Division of Endocrinology at the University of Virginia School of Medicine.

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